Healthcare Provider Details

I. General information

NPI: 1376685982
Provider Name (Legal Business Name): VINCENT L WILLIAMS DMD,PA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/12/2007
Last Update Date: 11/28/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

590 FALLS AVE
TWIN FALLS ID
83301-3314
US

IV. Provider business mailing address

590 FALLS AVE
TWIN FALLS ID
83301-3314
US

V. Phone/Fax

Practice location:
  • Phone: 208-734-3562
  • Fax: 208-736-8339
Mailing address:
  • Phone: 208-734-3562
  • Fax: 208-736-8339

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License NumberD1658-OS
License Number StateID

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: